Nokea
A nurse is caring for four clients who are postoperative from surgery 24 hr ago. At 1200 the nurse assesses the clients. Which of the following clients is the nurse's priority?
- A. A client who reports pain as 4 on a scale of 1 to 10 at 0800 now reports pain as 6
- B. A client whose wound drainage at 0800 was sanguineous and now it is serosanguineous
- C. A client who has a prescription for insulin and his premeal capillary blood glucose was 110 mg/dL and his post-meal capillary blood glucose is now 160 mg/dL
- D. A client whose blood pressure at 0800 was 138/86 mm Hg and at 1200 is 106/60 mm Hg
Correct Answer: D
Rationale: The correct answer is D because a significant drop in blood pressure from 138/86 mm Hg at 0800 to 106/60 mm Hg at 1200 indicates potential hypotension, which could be a sign of hemorrhage or shock postoperatively. Hypotension can lead to inadequate tissue perfusion and organ damage. Monitoring and addressing the client's blood pressure promptly is crucial to prevent further complications.
Choice A is not the priority because an increase in pain from 4 to 6 is significant but does not indicate as immediate risk as hypotension. Choice B, a change in wound drainage consistency, may require monitoring but is not as urgent as addressing hypotension. Choice C, an increase in post-meal blood glucose, is important but does not pose an immediate threat to the client's life compared to hypotension in Choice D.
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A nurse has received change-of-shift report and is delegating tasks to the assistive personnel (AP). The nurse should tell the AP to complete which of the following tasks first?
- A. Perform blood glucose monitoring of a client who has a prescription for short-acting insulin prior to breakfast.
- B. Apply a condom catheter to a client who is incontinent.
- C. Deliver a clean voided urine specimen to the laboratory.
- D. Feed a client who has bilateral casts due to upper arm fractures.
Correct Answer: A
Rationale: The correct answer is A: Perform blood glucose monitoring of a client who has a prescription for short-acting insulin prior to breakfast. This task should be completed first because it involves monitoring a client's blood glucose level to ensure safe administration of insulin. Insulin administration is time-sensitive and should be based on current blood glucose levels to prevent hypoglycemia or hyperglycemia. This task directly impacts the client's immediate health and safety, making it the priority.
Summary of other choices:
B: Applying a condom catheter can be important but is not as time-sensitive or critical as monitoring blood glucose levels for insulin administration.
C: Delivering a clean voided urine specimen is important but can often wait until after more urgent tasks are completed.
D: Feeding a client with bilateral casts is important, but it is not as time-sensitive as monitoring blood glucose levels for insulin administration.
A nurse is teaching a class on torts. The nurse should instruct the class that administering an antibiotic medication to a competent client after the client has refused it is an example of which of the following torts?
- A. False imprisonment
- B. Assault
- C. Battery
- D. Negligence
Correct Answer: C
Rationale: The correct answer is C: Battery. Battery is the intentional harmful or offensive touching of another person without consent. In this scenario, administering the antibiotic medication to a competent client after they have refused it constitutes a deliberate act of touching the client without their consent, which aligns with the definition of battery.
False imprisonment (A) involves restricting a person's freedom of movement unlawfully, which does not apply in this case. Assault (B) involves the threat of harmful or offensive contact, not the actual act itself. Negligence (D) is the failure to exercise proper care in a situation, which is not applicable here as the action was intentional.
A nurse is planning care for a client who has anorexia nervosa. The nurse should make which of the following client goals the priority?
- A. Identify changes within the family unit that promote the client's autonomy.
- B. Gain 2 pounds of weight per week.
- C. Make positive statements about improvements in body image.
- D. Feel in control of her behavior.
Correct Answer: B
Rationale: The correct answer is B: Gain 2 pounds of weight per week. In anorexia nervosa, the primary goal is to restore the client's weight to a healthy level to prevent serious health complications. Weight restoration is crucial in addressing the physical consequences of severe malnutrition and improving overall health. Gaining weight at a steady pace of 2 pounds per week is a realistic and safe goal.
Other choices are incorrect because:
A: Identifying changes within the family unit is important but not the priority compared to addressing the physical health concerns.
C: Making positive statements about improvements in body image is important for psychological well-being but does not address the immediate health risks associated with anorexia.
D: Feeling in control of behavior is a valid goal, but weight restoration takes precedence due to the critical nature of the client's physical health in anorexia nervosa.
A nurse is planning client care for herself and an assistive personnel (AP) working with her. Which of the following tasks should the nurse plan to perform?
- A. Assisting a client to cough and deep breathe
- B. Application of antiembolic stockings
- C. Administration of an enema
- D. Assessing a client's sacrum for edema
Correct Answer: D
Rationale: The correct answer is D. The nurse should plan to perform the task of assessing a client's sacrum for edema. This task requires critical thinking and nursing judgment to assess for potential complications such as pressure ulcers. Nurses are trained to assess and identify abnormalities in a client's condition.
Choice A: Assisting a client to cough and deep breathe can be delegated to the AP as it is within their scope of practice.
Choice B: Application of antiembolic stockings is a task that can be safely delegated to the AP as it is a routine procedure that does not require nursing assessment.
Choice C: Administration of an enema is a task that can be delegated to the AP as it is a routine procedure that does not require nursing assessment.
A nurse manager is providing an inservice program about delegation to assistive personnel (AP) with staff nurses on the unit. Which of the following statements by a staff nurse indicates an understanding of the teaching?
- A. The nurse relinquishes accountability for client outcomes when care is delegated to an AP.
- B. The nurse should consider the AP's level of experience when making delegation decisions.
- C. The AP can provide client education about how to perform basic self-care to the client.
- D. The AP can re-delegate a task to another AP who has similar work experience.
Correct Answer: B
Rationale: The correct answer is B: The nurse should consider the AP's level of experience when making delegation decisions. This answer demonstrates an understanding of the key principle of delegation, which is to assign tasks based on the competency and skill level of the individual. Considering the AP's experience ensures safe and effective delegation.
Incorrect choices:
A: Incorrect because the nurse remains accountable for client outcomes even when delegating tasks.
C: Incorrect because client education should typically be done by licensed healthcare providers.
D: Incorrect because delegation should not involve re-delegating tasks to another uninvolved AP.
In summary, choice B reflects the importance of assessing the AP's competency when delegating tasks, ensuring safe and quality care.